Attention-Deficit/Hyperactivity Disorder

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"I am one of the lucky mothers. I now understand why my son behaves the way he does. I know now that the disturbing behaviors which appeared at various stages of his development were neither of his own doings or my fault.

If you are the parent of a child with AD/HD, I want you to know that children with AD/HD aren't really pain in the neck kids with lousy parents. Understand that they are children who have AD/HD and know when and where to go for help and support."

From Mary Fowler's (1993), Maybe you know my kid: A parent's guide to identifying, understanding, and helping your child with ADHD (2nd cd ). Used with permission.

How is AD/HD Treated?

No cure or "quick fix" exists to treat AD/HD. The symptoms, however, can be managed through a combination of efforts. Management approaches need to be designed to assist the child behaviorally, educationally, psychologically, and, in many instances, pharmacologically.

Called multi-modal management, this approach consists of four basic parts: education about and understanding of AD/HD, behavior management, appropriate educational interventions, and, frequently, medication. In some instances, individual or family counseling is also advised.

AD/HD has been called an environmentally dependent disability. The significant people in the life of those who have AD/HD need to understand that difficulties will rise and fall in relation to the environment's demands and expectations. Problems often arise in environments where children are expected to be seen and not heard, to pay careful attention, and to use great self-control. Often, when children with AD/HD fall short of meeting these expectations, we try to change the children, rather than changing aspects of the environment, including our actions and reactions.

Parents and teachers need to be aware of the symptoms of AD/HD and how those symptoms impact the child's ability to function at home, in school, and in social situations. When the adults in the child's life understand the nature of the disorder, they will be able to structure situations to enable the child to behave appropriately and achieve success. Remember, the child who has difficulty with attention, impulse control, and in regulating physical activity needs help and encouragement to manage these problems.

From a thorough understanding of AD/HD comes a change in the way the child's behavior is viewed. This change sets the stage for the effective use of the other components of the AD/HD management system.

The main goal of all behavior management strategies is to increase the child's appropriate behavior and decrease inappropriate behavior. The best way to influence any behavior is to pay attention to it. The best way to increase a desirable behavior is to catch the child being good.

Behavior is defined as a specific act or actions. When thinking about managing behavior, many people focus on the act or actions. In actuality, behavior management is much broader. It takes into account that, before a specific act or action occurs, there is something that sets the stage for the act to happen (called an antecedent), and something that follows which either encourages or discourages a repetition of the act (called a consequence). Behavior management involves changing the antecedents and consequences so that the child's behavior changes.

Whether at home or in school, children with AD/HD respond best in a structured, predictable environment. Here, rules and expectations are clear and consistent, and consequences are set forth ahead of time and delivered immediately. Demands are limited. Rewards are plenty. Praise is frequent. Negative feedback is minimal.

By establishing structure and routines, preparing the child for changes in the routine, building opportunities for the child to be successful, setting consequences ahead of time, and anticipating where difficulties may arise, parents and teachers can change the antecedents and cultivate an environment that encourages the child to behave appropriately. When adults in the child's life do what they say they are going to do, and do so on a consistent basis so that the child knows their word has meaning, then they are providing the consequences to encourage the child to continue behaving appropriately, plus discouraging any undesired behavior.

Behavior management is a skill. It requires practice, and it requires patience. Changing behavior takes time.

Behaviorally trained professionals often encourage the use of behavior modification charts. Charts are designed to provide the child with a clear picture of what behaviors are expected. The child then has the choice of whether to meet those expectations. Parents or teachers provide feedback to the child about his or her choices by delivering consequences. Charts provide high motivation and enable the child to develop an internal sense of self-control, specifically, that he or she can behave appropriately.

There are two basic types of chart programs. (1) Token Economy: Here, the child earns tokens (chips, stickers, stars) for appropriate behavior. Tokens can be exchanged for various rewards. (2) Response Cost: In this chart program, the child is given tokens for free. Tokens are withdrawn for inappropriate behavior (e.g., out of seat, off-task, etc.).

The most effective programs use both types of chart systems and work on a give-and-take basis. In this combination system, the child is given a token for behaving appropriately and loses a token when misbehaving.

When creating and implementing a behavior modification chart, you may wish to follow these suggestions:

• Make a list of problematic behaviors or ones that need improving.
  
  
• Select the behaviors to be modified. Parents (or teachers), with input from the child, review the list of problematic behaviors and select three, four, or five to work on at a given time. The behaviors charted should be ones that occur daily, such as going to bed on time, doing homework, or getting ready for school on time.
  
  
• Design a reward system (Token Economy, Response Cost, or a combination). Parents (or teachers) need to pay attention to the child's behavior throughout the course of the day and provide frequent rewards when the child behaves appropriately. At the end of the day, tokens can be exchanged for rewards, such as extended bed time, playing a game with Mom or Dad, or a favorite snack. Remember, a reward is only effective when it has value to the child. Rewards might have to be changed frequently.
  
  

About Punishment: Children with AD/HD respond best to motivation and positive reinforcement. It is best to avoid punishment. When punishment is necessary, use it sparingly and with sensitivity. It is important for parents and teachers to respond to this child's inappropriate behavior without anger and in a matter-of-fact way. These children need to be taught to replace inappropriate behavior with appropriate behavior.

About Time-out: When the child is misbehaving or out of control, time-out is an effective way to manage the problem. Time-out means the child is sent to a predetermined location for a short period of time. A place out of the mainstream of activity is best; for example, one particular chair may be specified as the "time-out chair." The time-out location should not be a traumatic place, such as a closet or dark basement. The purpose of time-out is to provide the child with a cooling-off period wherein he or she can regain control.

An important aspect to time-out is that the child no longer has the privilege of choosing where he or she would like to be or how time is spent. In general, the child stays in time-out and must be quiet for five minutes. Preschool-aged children are usually given two or three minutes in time-out. For toddlers, 30 seconds to a minute is appropriate.

Medication has proven effective for many children with AD/HD. Most experts agree, however, that medication should never be the only treatment used. The parents' decision to place a child on medication is a personal one and should be made after a thorough evaluation of the child has taken place and after careful consideration by both the parents and the physician.

Stimulants are the medication most widely prescribed for AD/HD. These drugs, for example, Ritalin (the most widely used), Dexedrine, Cylert, are believed to stimulate the action of the brain's neurotransmitters, which enables the brain to better regulate attention, impulse, and motor behavior. In general, the short-acting stimulant medications (e.g., Ritalin, Dexedrine) have few and mild side effects. For children who cannot take stimulant drugs, anti-depressant medications or Clonidine are used.

The prescribing physician should explain the benefits and drawbacks of medication to the parents and, when appropriate, to the child. Doses are generally administered gradually, so that the child receives the lowest dose needed to achieve the best therapeutic benefit. Parents should dispense the medication as prescribed and monitor closely how their child responds to the medication, including side effects. Such monitoring generally includes feedback from the child's teacher(s), which is usually based on the use of behavior rating scales. Parents should communicate with the physician as often as is necessary to determine when medication has reached the proper level for the child, and to discuss any problems or questions.

A note of caution: Many parents and teachers have heard that mega-vitamins, chiropractic scalp massage, visual/ocular motor training, biofeedback, allergy treatments, and diets are useful treatments for AD/HD. However, these treatments have not been recommended by AD/HD experts for the simple reason that they have not stood up under careful scientific scrutiny. As their child's primary caregivers and advocates, parents need to become informed consumers and exercise caution when considering such treatments.

Many children with AD/HD experience the greatest difficulty in school, where demands for attention and impulse and motor control are virtual requirements for success. Although AD/HD does not interfere with the ability to learn, it does wreak havoc on performance. Thus, in the school arena, AD/HD is an educational performance problem. When little or nothing is done to help these children improve their performance, over time they will evidence academic achievement problems. This underachievement is not the result of an inability to learn. It is caused by the cumulative effects of missing important blocks of information and skill development that build from lesson to lesson and from one school year to the next.

Generally, AD/HD will affect the student in one or more of the following performance areas:

• starting tasks,
  
  
• staying on task,
  
  
• completing tasks,
  
  
• making transitions,
  
  
• interacting with others,
  
  
• following through on directions,
  
  
• producing work at consistently normal levels, and
  
  
• organizing multi-step tasks.
  
  

Those teaching or designing programs for these students need to pinpoint where each student's difficulties occur, Otherwise, valuable intervention resources may be spent in areas where they are not critical. For example, one child with AD/HD may have difficulty starting a task because the directions are not clear, while another student may fully understand the directions but have difficulty making transitions and, as a result, get stuck in the space where one task ends and another begins. With the first child, intervention needs to focus upon making directions clear and in helping the child to understand those directions. The second child would need help in making transitions from one activity to another.

The sooner educational interventions begin, the better. They should be started when educational performance problems become evident and not delayed because the child is still holding his or her own on achievement tests.